New-onset vitiligo and progression of pre-existing vitiligo during treatment with biological agents in chronic inflammatory diseases

BACKGROUND

The development of vitiligo during treatment with biological agents is an unusual event and only a few isolated cases have been reported.

OBJECTIVES

To describe the clinical characteristics and evolution of patients developing new-onset vitiligo following initiation of a biological agent for chronic inflammatory disease; and also to report the clinical course of pre-existing vitiligo under biological therapy.

METHODS

This nationwide multicentre, retrospective study, carried out between July 2013 and January 2015, describes the characteristics of a large series of 18 patients (psoriasis N = 8, inflammatory rheumatic diseases N = 8, ulcerative colitis N = 1, uveitis N = 1) who developed new-onset vitiligo while receiving a biological agent.

RESULTS

TNFα inhibitors were the most common biological agent involved (13/18) while anti-IL-12/23 and anti-IL-17 agents or abatacept were less common (4/18 and 1/18 respectively). Mean duration of biological agent exposure before vitiligo onset was 13.9 ± 16.5 months. Outcome was favourable for most patients (15/17) while maintaining the biological agent. Data were also collected for 18 patients (psoriasis N = 5, inflammatory rheumatic diseases N = 10, inflammatory bowel diseases N = 2, SAPHO N = 1) who had pre-existing vitiligo when treatment with a biological agent started (TNFα inhibitors N = 15, ustekinumab N = 1, rituximab N = 1, tocilizumab N = 1). Vitiligo progressed in seven patients and was stable or improved in eight cases.

CONCLUSION

Vitiligo may thus emerge and/or progress during treatment with various biological agents, mainly TNFα inhibitors and could be a new paradoxical skin reaction. De novo vitiligo displays a favourable outcome when maintaining the biological agent, whereas the prognosis seems worse in cases of pre-existing vitiligo.

Prognostic value of antibodies to Merkel cell polyomavirus T antigens and VP1 protein in patients with Merkel cell carcinoma

BACKGROUND

Merkel cell polyomavirus (MCPyV) is the main aetiological agent of Merkel cell carcinoma (MCC). Serum antibodies against the major MCPyV capsid protein (VP1) are detected in the general population, whereas antibodies against MCPyV oncoproteins (T antigens) have been reported specifically in patients with MCC.

OBJECTIVES

The primary aim was to assess whether detection of serum antibodies against MCPyV proteins at baseline was associated with disease outcome in patients with MCC. The secondary aim was to establish whether evolution of these antibodies during follow-up was associated with the course of the disease.

METHODS

Serum T-antigen and VP1 antibodies were assessed by enzyme-linked immunosorbent assay using recombinant proteins in a cohort of 143 patients with MCC, including 84 patients with serum samples available at baseline.

RESULTS

Low titres of VP1 antibodies at baseline (< 10 000) were significantly and independently associated with increased risk of recurrence [hazard ratio (HR) 2·71, 95% confidence interval (CI) 1·13-6·53, P = 0·026] and death (HR 3·74, 95% CI 1·53-9·18, P = 0·004), whereas T-antigen antibodies were not found to be associated with outcome. VP1 antibodies did not differ between patients in remission and those with recurrence or progression during follow-up. However, T-antigen antibodies were more frequently detected in patients with recurrence or progression at 12 months (P = 0·020) and 24 months (P = 0·016) after diagnosis.

CONCLUSIONS

VP1 antibodies constitute a prognostic marker at baseline, whereas T-antigen antibodies constitute a marker of disease recurrence or progression if detected > 12 months after diagnosis.

A multicentre study to determine the value and safety of drug patch tests for the three main classes of severe cutaneous adverse drug reactions

BACKGROUND

Drug patch tests (PTs) can reproduce delayed hypersensitivity to drugs and entail a moderate re-exposure of patients to offending drugs.

OBJECTIVES

To determine the value of PTs for identifying the responsible drug in severe cutaneous adverse drug reactions (SCARs) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN).

METHODS

In a multicentre study, PTs were conducted on patients referred for DRESS, AGEP or SJS/TEN within 1 year of their SCAR. All drugs administered in the 2 months prior to and the week following the onset of the SCAR were tested.

RESULTS

Among the 134 patients included (48 male, 86 female; mean age 51·7 years), positive drug PTs were obtained for 24 different drugs. These included positive tests for 64% (46/72) of patients with DRESS, 58% (26/45) of those with AGEP and 24% (4/17) of those with SJS/TEN, with only one relapse of AGEP. The value of PTs depended on the type of drug and the type of SCAR (e.g. carbamazepine was positive in 11/13 DRESS cases but none of the five SJS/TEN cases). PTs were frequently positive for beta lactams (22 cases), pristinamycin (11 cases) and in DRESS with pump proton inhibitors (five cases), but were usually negative for allopurinol and salazopyrin. Of 18 patients with DRESS, eight had virus reactivation and positive PTs. In DRESS, multiple drug reactivity was frequent (18% of cases), with patients remaining sensitized many years later.

CONCLUSIONS

PTs are useful and safe for identifying agents inducing SCAR.

Vitamin D deficiency is associated with greater tumor size and poorer outcome in Merkel cell carcinoma patients

BACKGROUND

Merkel cell polyomavirus has been recognized to be associated with Merkel cell carcinoma (MCC), but the evolution of this cancer probably depends on various factors. Vitamin D deficiency, defined by serum 25-hydroxyvitamin D levels <50 nmol/L, seems to influence cancer behavior and progression, but has never been assessed in MCC patients.

OBJECTIVES

First, to evaluate whether vitamin D deficiency was associated with tumor characteristics and prognosis in a cohort of MCC patients. Second, to assess expression of the vitamin D receptor (VDR) in MCC tumors.

METHODS

Clinical findings, Merkel cell polyomavirus markers and vitamin D status were assessed in a cohort of French MCC patients. The study was limited to the 89 patients for whom the serum sample had been collected within 3 years after the diagnosis of MCC. Correlation between vitamin D deficiency and MCC characteristics and outcome were determined in regression analyses. VDR expression in MCC tumours was assessed by immunohistochemistry.

RESULTS

Vitamin D deficiency was noted in 65.1% of the patients and was independently associated with greater tumor size at diagnosis (P = 0.006) and with metastasis recurrence (HR, 2.89; 95% CI, 1.03 to 8.13; P = 0.043), but not with death from MCC, although there was a trend (HR, 5.28; 95% CI, 0.75 to 36.96; P = 0.093). VDR was found to be strongly expressed in all 28 MCC tumor specimens investigated.

CONCLUSION

The association between vitamin D deficiency and MCC characteristics and outcome, together with detection of the VDR in MCC cells, suggest that vitamin D could influence the biology of MCC.

[Photopatch testing]

This article reminds a review of photopatch tests with detailed analysis of: (1) materials used for double patch tests, and where possible, triple copies, one of which is protected from light while the other is exposed to UVA (5mJ/cm2) and the other exposed to UVB or a total spectrum of 0.75 DEM (minimum erythematous dose), with at least two readings; (2) interpretation of results to distinguish between contact allergy, contact photoallergy and/or phototoxicity; (3) materials used for UV exposure; (4) the list of (photo)allergens used in a standard series and/or a series specifically suited to the patient as well as suppliers of such series; (5) finally, the circumstances prompting photodermatological exploration.

[Cutaneous angiosarcoma of the leg without lymphoedema]

BACKGROUND

Cutaneous angiosarcoma is a rare aggressive vascular neoplasm with a poor prognosis, seen chiefly in elderly subjects and usually on the scalp or face. The present case is original because of its localization on the leg without any chronic lymphoedema and because of the long survival period. The treatment modalities are discussed.

CASE REPORT

An 87-year-old woman presented with a rapidly growing large deep-purple ulcerated tumour on the anterior aspect of the leg. In addition, two nodules with a similar aspect appeared on the outer surface of the foot. Histological examination showed vascular channels lined with atypical cells consistent with a diagnosis of angiosarcoma. Computed tomography revealed no metastases. Amputation was performed at the thigh and there was no recurrence 30 months later.

DISCUSSION

The leg is a rare site of cutaneous angiosarcoma. Treatment usually consists of surgical excision with wide margins followed by radiotherapy, but in some cases amputation is unavoidable.

Dermatite purpurique de contact au suc d’Agave americana

BACKGROUND

Irritant papulovesicular dermatitis after cutaneous exposure to the sap of Agave Americana, which contains chemical irritants such as calcium oxalate and saponins, is well known, but purpuric dermatitis is rare in such cases.

CASE REPORT

We report the case of a 52 year-old man with purpuric dermatitis of the legs mimicking purpura vasculitis that appeared a few hours after he had cut down a large Agave with a chain-saw.

DISCUSSION

Our case is quite similar to three other cases found in the literature. In all four cases the patients had been using machines causing projections of plant fragments (chain-saw, trimmer). This may have promoted vascular damage, either by direct traumatism or by embedding oxalate crystals and saponins in the skin close to small vessels.

Allergie de contact aux antiseptiques : 75 cas analysés par le réseau Revidal de dermato-allergovigilance

AIM

To determine the clinical features of contact dermatitis caused by antiseptics and to ascertain whether the substance responsible is the antiseptic itself or the excipients.

PATIENTS AND METHODS

A multicenter, retrospective study based on analysis of all cases reported over a 2-year period to the Dermato-Allergology Vigilance network known as Revidal. Each dossier contained details of the clinical characteristics of lesions, the incriminated antiseptic, the mode of exposure and the results of patch tests done with the antiseptic in question.

RESULTS

75 patients (mean age: 44 years) were sensitized to chlorhexidine (14 cases), hexamidine (20 cases), povidone iodine (14 cases), mercuric antiseptics (3 cases), triclocarban (Septivon, 17 cases), hexamidine-chlorhexidine-chlorocresol (Cytéal, 4 cases), or chlorhexidine surfactant (Hibiscrub), cetrimide or chlorhexidine digluconate (Diaseptyl) (1 case each). Exposure was therapy-related (68 cases), work-related (6 cases; 5 in health workers and 1 in a cattle farmer due to povidone-iodine) or related to cosmetics (1 case, hexamidine). The clinical features consisted mainly of localized contact dermatitis, although generalized eczema occurred in 9 cases due to hexamidine contact. Sensitization was due to the antiseptic itself (53 cases) or to the excipients alone (22 cases), particularly in the 17 cases caused by Septivon. In 27/75 cases (35%), patients exhibited polysensitization to antiseptics belonging to different chemical classes or to other topical drugs.

CONCLUSION

Sensitization to antiseptics is probably not rare, with various sources of exposure being present in everyday life. Patch tests are essential for diagnosis in order to distinguish between antiseptic-related and excipient-related sensitization and to screen for polysensitization to topical drugs.

[Congenital adipose plantar nodules persisting in a 28 year-old woman]

INTRODUCTION

Congenital adipose plantar warts, a recently individualized entity, have an unknown long term evolution. Our patient, seen again aged 28 years represents the longest follow-up of the affection in the literature.

OBSERVATION

A young woman presented with congenital plantar nodules. She was seen again at the age of 28: the lesions were still present and made it difficult for her to walk.

DISCUSSION

Congenital adipose plantar warts are characterized by a bilateral, asymptomatic, plantar nodule of the heel, present at birth, corresponding histologically to a normal hypodermis, occasionally with interlobular fibrosis. The follow-up of published cases has only covered childhood. Our observation suggests the persistence of the affection into adulthood. It also emphasizes the possible functional problem created when walking.

Contact dermatitis from electrocardiograph-monitoring electrodes: role of p-tert-butylphenol-formaldehyde resin

Three cases of allergic contact dermatitis localized to the sites of electrocardiograph-monitoring electrodes are reported. All patients had positive patch tests to both the gel and the adhesive part of the Red Dot 2239 3M monitoring electrode used and to the p-tert-butylphenol-formaldehyde resin (PTBP-F-R) of the standard series. Two patients had a history of possible exposition to the resin previously but there was no explanation for the third. No information about the presence of PTBP-F-R in the electrodes could be obtained from the manufacturers. Chemical analysis of samples of the electrode, using a gas chromatography-mass spectrometry (GC-MS) and high pressure liquid chromatography (HPLC) analytical system, demonstrated the presence of several PTBP-F-R derivatives in both the gel and the adhesive part.

An epidemic of allergic contact dermatitis due to epilating products

Over a period of 19 months, 33 cases of acute allergic contact dermatitis from Veet epilating waxes and/or the accompanying tissue (Reckitt Benckiser, Massy, France) were observed in France and Belgium. The lesions started on the legs and spread to other parts of the body, especially the face, and were sometimes so severe that hospitalization and/or systemic corticosteroids were required. Primary sensitization occurred as early as after the first application in several patients. Patch tests were performed in 26 of the patients and produced strong positive reactions to the tissue (25 times) and/or the wax (13 times). The allergenic culprits in the wax were modified-colophonium derivatives (colophonium in the standard series testing negatively in all except 4 patients), while methoxy PEG-22/dodecyl glycol copolymer and to a lesser degree lauryl alcohol turned out to be the main causal allergens in the tissue.